Healthcare Provider Details

I. General information

NPI: 1831562842
Provider Name (Legal Business Name): CREATIVE LIVING COMMUNITY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 02/29/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH ST.
WINDSOR CT
06095-1100
US

IV. Provider business mailing address

200 HIGH ST.
WINDSOR CT
06095-1100
US

V. Phone/Fax

Practice location:
  • Phone: 860-640-0660
  • Fax: 860-640-4836
Mailing address:
  • Phone: 860-640-0660
  • Fax: 860-640-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHCA0000240
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: MR. CLEMENT POWNALL
Title or Position: PRESIDENT
Credential:
Phone: 860-640-0660